FORM NO.

10-IA
[See sub-rule (2) of rule 11A]
Certificate of the medical authority for certifying ‘person with disability’, ‘severe
disability’, ‘autism’, ‘cerebral palsy’ and ‘multiple disability’ for purposes of section
80DD and section 80U

Certificate No.
Date :

This is to certify that Shri/Smt./Ms. _______________________________ son/daughter of

Shri _________________________________ , age ______ years ___________ male/female*
residing at ____________________________________ , Registration No. __________ is a
person with disability/severe disability* suffering from autism/cerebral palsy/multiple
disability*.

2. This condition is progressive/non-progressive/likely to improve/not likely to improve*.

3. Reassessment is recommended/not recommended after a period

of __________ months/years*.

Sd/-
(Neurologist/Pediatric Neurologist/Civil Surgeon/

Chief Medical Officer*)

Name : ___________________

Address of Institution/Government hospital :

____________________________________

____________________________________

Qualification/designation of specialist : ____________________

SEAL Signature/Thumb impression* of the patient

Note : *Strike out whichever is not applicable.
* of the patient
s not applicable.